Section 144-115-34 - METHOD OF PAYMENT34.1Per Diem Costs34.1.1For DHHS Licensed Facilities-Appendix C (Other than Adult Intellectual Disability Facilities): Principle. Payment of routine services costs will be made prospectively by the Department using audited 1998 costs (as filed or pro forma costs used in rate setting for new facilities) as a base year, inflated by the DRI index to July 1, 2001. The Department will set the routine services per diem for each facility at the lesser of the facility-specific inflated base year rate or the upper limit, whichever is less, and as of July 1, 2004, will reduce this amount by twenty-fivecent (25¢) per diem. This becomes the facility-specific cap. Providers will be reimbursed for the average annual per diem cost for routine services up to the facility-specific cap. The average annual per diem cost for routine multiplied by bed days of care provided to members will determine reimbursement. Routine costs will be off set by the program allowance paid by the MaineCare program in accordance with Section 33.
Effective July 1, 2001, the Commissioner of DHHS has set the gross upper limit on routine costs per day at twenty-four dollars and ninety-five cents ($24.95) for facilities with twenty-four (24) or fewer beds, twenty-eight dollars and fifteen cents ($28.15) for facilities with twenty-five (25) or more beds, and thirty-two dollars and seventy cents ($32.70) for specialty Alzheimer's facilities. This will be offset by the program allowance. For facilities that receive MaineCare payments for medical and remedial services under Section 97, Chapters II and III, Appendix C of the MBM, the Department may approve routine costs in excess of these amounts upon justification by the provider. In that event, the approved costs become the facility-specific caps, and the facility will not be subject to the upper limit contained in Section 34.1.1. In either event, as of July 1, 2004, the Department will reduce that amount by twenty-five cent (25¢) per diem.
34.1.2For DHHS Licensed Facilities-Appendix F-Office of Aging and Disability Services Effective July 1, 2001, DHHS Aging and Disability Services has set the upper limit on routine per diem costs at fourteen dollars and six cents ($14.06). This is the net after the program allowance has been offset. Subsequent to that date, the upper limit will be adjusted annually to reflect the DRI index. For facilities funded by DHHS Aging and Disability Services, costs will be set prospectively using audited FY 1996 costs, removing medical supplies, inflated by the DRI index for FY 2001. Routine costs will be offset by the program allowance paid by the MaineCare Program in accordance with Section 33.
34.2Bed-Hold Days Providers may be reimbursed for up to thirty bedhold days per calendar year when the resident is absent from the facility. Billing codes are BL and MRBL.
34.3Occupancy Adjustments34.3.1Principle. To the extent that per diem costs are allowable, such costs will be adjusted for providers with one (1) level of care whose annual level of occupancy is less than ninety percent (90%). The adjustment to the per diem costs shall be based on a theoretical level of occupancy of ninety percent (90%). The above percentage level is eighty percent (80%) in those facilities licensed as Level III facilities.
34.3.1(a) For new providers whose first fiscal year of operation for audit reporting purposes will include nine months or less, the actual member census will be used, and the cap on routine services will bewaived. For new providers coming into the system whose first fiscal year of operation for audit reporting purposes will include a period of time greater than nine (9) months, the ninety percent (90%) (and 80% in those facilities licensed as Level III facilities), occupancy adjustment will not apply for the first ninety (90) days of operation.34.3.1(b) For all subsequent cost reporting periods after the reporting periods addressed in Section 34.3.1(a), the ninety percent (90%) and eighty percent (80%) occupancy requirements as stated in Section 34.3.1 will apply.34.3.2Persons Living in Facilities Who Are Not Members.In the event owners, employees, or others reside in the facility, all costs will be pro-rated over the total number of people residing there. Only those pro-rated costs related to serving members will be considered as allowable costs. Only the pro-rated share of utilities and food will be deducted in determining allowable costs in non-profit facilities, because the live-in staff has no ownership in the non-profit home. The following factors will be considered in determining if persons are residing in the facility: they generally treat the facility as if it were their home, they have no other permanent residence, they receive personal mail at the facility, they maintain their personal belongings at the facility, or they sleep in the facility, or they sleep in the facility for extended periods of time.34.4Rates for New Facilities34.4.1Principle. For facilities opened after July 1, 2001, the Department must approve a facility's initial routine and capital/fixed costs in order to receive payment under these Principles. A pro forma cost report and supporting documentation detailing the provider's total operating costs, including proposed direct care costs that will be covered by MaineCare, routine operating costs and capital/fixed costs, must be submitted in order to establish the initial interim rate. Required data includes ownership interests, related partyinterests, projected financial statements, sources and uses of funds, terms of any new or existing borrowing, detail of the total estimated/actual project costs such as for land, building/renovations/construction, equipment and soft costs, depreciation schedule, startup cost budget, and staffing schedule. This information will be provided on forms approved by the Department and must be of sufficient detail to substantiate costs projected on the pro forma cost report. The capital cost data will be reviewed by the Department and a calculation will be made of the maximum amount that the Department may reimburse for depreciation expense, interest expense, and start-up costs, there by, establishing the provider's depreciable basis or historical cost. The interim rate for routine costs will be approved at the lesser of the pro forma cost report or the estimate average routine costs for the industry. Future routine cost caps will be established based on the audited costs for the first complete year of operation, subject to the upper limit.34.4.2 The interim payment rate will be used to calculate over or underpayment to the provider after the provider submits a report of actual operating expenses and financial statements and the DHHS, Division of Audit, completes an audit of the provider's records.34.4.3 Subsequent rates for the routine component will be calculated by taking the audited allowable routine costs (subject to the upper limit) for the first complete operating period and inflating them forward to the rate setting period. Capital/fixed costs will be based on actual allowable costs for the prior year and will not be inflated.34.5Final Settlements34.5.1 After completion of the final audit, all overpayments or underpayments will be adjusted on a lump sum basis or as stated in Section 15. The final audit may consist of a full scope examination by the DHHS, Division of Audit personnel, and will be conducted on an annual basis. Reimbursement will be limited to the total actual allowable fixed and routine service costs, not to exceed the facility-specific cap set for routine service costs per Section 34.1.1. These total allowable costs shall be divided by the actual number of bed days, or ninety percent (90%) of licensed capacity, whichever is greater (five (5) and six (6) bed facilities may use eighty percent ( 80%) of licensed capacity), in order to determine a cost per bed day.
The cost per bed day shall be multiplied by the number of MaineCare eligible days to determine the total reimbursable costs.
Final settlement consists of allowable costs determined through the audit, compared to the interim payments received by the provider.
34.6Recovery of Overpayments34.6.1 The Department will recover overpayments made to a provider either by set-off, recoupment, or any other method allowed by law.34.6.2 The Department may withhold payment on pending or future claims in an amount equal to the overpayment. The amount may be withheld all at once or over a period of time established by the Department. Amounts are to be repaid within ninety (90) days of the date the audit is finalized unless otherwise negotiated with the Department.34.6.3 Should there be insufficient claims sent to the Department against which the Department can set-off the amount of an overpayment, the provider shall be directed to remit payment in full. If repayment is not made, the Department may exercise any or all appropriate action against the provider and exercise all other civil remedies in order to recover the overpayments.34.7Appeal Procedure34.7.1 A facility may administratively appeal any of the following types of determinations through the DHHS, Division of Audit: 34.7.1(a) Audit adjustments and calculation of an audited per diem rate;34.7.1(b) Adjustments to per diem rate;34.7.1(c) Historical costs.34.7.2 Administrative appeals will proceed in the following manner: 34.7.2(a) Within sixty (60) days of receipt of an audit or other appealable determination, the facility must request, in writing, an informal review before the Director, DHHS, Division of Audit or his/her designee. The facility must forward with the request, any and all specific information that is relative to the issues in dispute, note the monetary amount each issue represents, and identify the appropriate principle supporting the request. Only issues presented in this manner and time frame will be considered at an informal review or at subsequent administrative hearing.34.7.2(b) The Director or his/her designee shall notify the provider in writing of the decision made as a result of such informal review. If the provider disagrees with the result of the informal review, the provider may request an administrative hearing before the Commissioner or a presiding officer designated by the Commissioner. Only issues presented in the informal review will be considered at the administrative hearing. A request for an administrative hearing must be made, in writing, within sixty (60) days of receipt of the decision made as a result of the informal review. The hearing shall proceed in accordance with the Department's Administrative Hearings Manual.34.7.2(c) To the extent the Department rules in favor of the facility, the audit report will be corrected.34.7.2(d) To the extent the Department upholds the original determination of the DHHS, Division of Audit, that decision may be appealed pursuant to the Administrative Procedure Act, 5 M.R.S.A. §11001et seq.34.7.3 A facility may administratively appeal any of the following types of determinations through the DHHS, Office of Rate-Setting: 34.7.3(a) Regulatory Compliance Costs34.7.3(b) Extraordinary Circumstances Allowance34.7.4 Administrative appeals will proceed in the following manner: 34.7.4(a) Within sixty (60) days of receipt of a Rate-Setting determination outlined in 34.7.3, the facility must make the request, in writing and addressed to the Director of MaineCare Services. This review will be conducted by the Director of MaineCare Services, or other designated Department representative who was not involved in the decision under review. The informal review will consist solely of a review of documents in the Department's possession including submitted materials/documentation and, if deemed necessary by the Department, it may include a personal meeting with the provider to obtain clarification of the materials. Issues that are not raised by the provider through the written request for an informal review or the submission of additional materials for consideration prior to the informal review are waived in subsequent appeal proceedings. The request for informal review may not be amended to add further issues. A written report of the decision resulting from the informal review will be issued to the provider.
34.7.4(b) A provider must properly request an informal review and obtain a decision before requesting an administrative hearing. If the provider is dissatisfied with the informal decision, he or she may write the Commissioner of the Department of Health and Human Services to request a hearing, provided he/she does so within sixty (60) calendar days of the date of receipt of the informal review report on the Department's action. Subsequent appeal proceedings will be limited only to those issues raised during the informal review process. The Office of Administrative Hearings shall notify the provider in writing of the date, time, and place of the hearing, and shall designate a presiding officer. Providers and provider applicants will be given advance notice of the hearing at least twenty (20) calendar days from the mailing date. The hearing shall be held in conformity with the Maine Administrative Procedure Act, 5 M.R.S. §8001et seq. and the Administrative Hearings Regulations.
The presiding officer shall issue a written decision and findings of fact to the provider or, pursuant to provisions of the Administrative Hearings Regulations, issue a written recommendation to the Commissioner of Health and Human Services. The Commissioner will then make the final decision. Legal counsel may represent providers and provider applicants at a hearing, and may request or subpoena persons to appear at the hearing where they can be expected to present testimony or documents relating to issues at the hearing.
If the provider is dissatisfied with the final decision, an appeal may be taken to the Superior Court pursuant to the Administrative Procedure Act.
34.7.5Informal Review Prior ApprovalsA.For Appendix C Medical and Remedial Service Facilities:If DHHS denies a request in whole or in part for approval of any item requiring prior approval, the provider may request an informal review of the decision from the Division of Licensing and Certification. A request for informal review must be made to the Director, Office of MaineCare Services, 11 State House Station, Augusta, Maine 04333-0011, within sixty (60) days of the denial. Any further appeal will proceed according to Section 34.7.2(b) of these Principles.
B.For Appendix F Non-Case Mixed Medical and Remedial Services Facilities If DHHS Office of Aging and Disability Services denies a request in whole or in part for approval of any item requiring prior approval, the provider may request an informal review of the decision. A request for informal review must be made to DHHS Office of Aging and Disability Services, Program Director, Intellectual Disability Services, 11 State House Station, Augusta, Maine 04333-0011 within sixty (60) days of the denial. The request for review shall state the reasons for the request and shall be accompanied by any supporting documentation. The program director shall forward a written response to the provider within sixty (60) days of receipt of a complete request for review. If the decision of the program director is denied, any further appeal shall follow 14-191 CMR Chapter 40, of the service agreement.
34.8Deficiency Per Diem Rate34.8.1 When certain conditions relating to these Principles are found in a facility receiving payment under these Principles, the Department may reduce reimbursement to ninety percent (90%) of the provider's per diem rate. This "deficiency rate" will be applied thirty (30) days following the provider's receipt of written notice of the specific condition that exists. If the provider can present documentation prior to the effective date of the "deficiency rate" that the condition no longer exists, the "deficiency rate" will not be applied. If the condition is not corrected, a reduction in rate will remain in effect until the records are corrected and verified by the DHHS, Division of Audit. Written notification of whether the Department believes the deficiencies have been corrected will be sent to the provider. No retroactive adjustments to the full rate shall be made for the period that the "deficiency rate" is in effect if it is properly invoked. Conditions under which a ninety percent (90%) "deficiency rate" will be invoked include:
34.8.1(a) Failure to submit a cost report and financial statement within five (5) months of the end of the provider's fiscal period.34.8.1(b) Failure to produce accurate and auditable financial and statistical records in sufficient detail to substantiate at least ninety-eight percent (98%) of total costs reported by the provider. Required records are described in Section 18. 34.8.2 If the provider can produce verifiable records to document at least ninety-eight percent (98%) of its reported expenses, then the undocumented expenses will be disallowed but no "deficiency rate" will be applied.34.8.3 When a "deficiency rate" has been in effect for three (3) months and the deficient condition has not been corrected, the provider may be notified of the suspension of the Provider Agreement and/or Service Agreement. This will be effective one month from receipt of notice.The Department will not reimburse the provider for any services provided after the effective date of the suspension of the Provider Agreement/Service Agreement. The provider shall submit a final cost report in the case of termination of the Provider Agreement/Service Agreement in accordance with the cost reporting requirements.34.9Inflation Adjustment The Commissioner of the Department will determine if an inflation adjustment will be made and the amount of that adjustment.
For the state fiscal year ending June 30, 2020 and each year thereafter, the MaineCare payment rates attributable to wages and salaries in routine services costs for Appendix C PNMIs must be increased by an inflation factor in accordance with the United States Department of Labor, Bureau of Labor Statistics Consumer Price Index - medical care services index.
10- 144 C.M.R. ch. 115, § 34